The Evolution Of Trauma-Focused Cognitive Behavioral .

The Evolution of Trauma-Focused CognitiveBehavioral Therapy (TF-CBT)Anthony P. Mannarino, Ph.D.Professor and Vice ChairDirector, Center for Traumatic Stress in Children and AdolescentsDepartment of PsychiatryAllegheny General HospitalDrexel University College of MedicinePittsburgh, PA

Types of Childhood Trauma Sexual abuse or assaultPhysical abuseWitness to domestic violenceVictim or witness of community violenceVictim or witness of school violenceBullyingSuicideMotor vehicle or other travel-related accidentsWeather-related eventsTerrorismMass disastersKidnapping; fires, etc.

Medical Trauma CancerBurnsTransplant or other life-threatening proceduresMutilating accidental or intentional injuryOther causes of loss or death of loved ones; vicarioustrauma

Traumatic Exposure Among Childrenand Adolescents 2/3 of youth age 16 and older have experienced traumatic lifeevents 25% of all girls and 10-15% of all boys have been sexuallyassaulted by their 18th birthday 20-25% of all youth have witnessed intimate partner violence School and electronic media bullying Suicides and other traumatic losses

Trauma Impact Acute distress almost universal Impact can be long lasting Childhood trauma is risk factor for numerousadult psychiatric and medical problems Impact varies; most recover over time withouttreatment but a significant minority willdevelop moderate to serious PTSDsymptoms and will require treatment

Long-term Consequencesof Untreated Childhood PTSD Significant risk for depression and other psychiatricdisorders PTSD is highly correlated with the development of drug andalcohol problems

Identification and Services forTraumatized Children Majority of traumatized children are not identified An even smaller number are evaluated and receivetreatment Traumatized children who do receive treatment donot typically receive evidence-based treatments(EBTs)

Clinical Presentation ofTraumatized Children Most traumatized children present with behavioralproblems at mental health clinics They may never be asked about their trauma history Treatment for behavior problems may be ineffectivebecause of the neglect of the trauma exposure Outcomes may worsen over time and may result inhigher levels of care (group homes; residential, etc.)

Major Barriers to Trauma Treatment Fear of retraumatizing the child Vicarious traumatization “Our clients are different”

Early Development of TF-CBT Deblinger in New Jersey- Influenced by work with Edna Foa, Ph.D.- RCTs with children exposed to sexual abuse- Focus on gradual exposure Cohen & Mannarino- RCTs with children exposed to sexual abuse and DV- Focus on cognitive processing and “making meaning” First combined RCT funded by the NIMH- 1997

Trauma-Focused Cognitive Behavioral Therapy(TF-CBT)A hybrid treatment model that integrates: Trauma sensitive interventions Cognitive-behavioral principles Attachment theory Developmental Neurobiology Family Therapy Empowerment Therapy Humanistic Therapy

TF-CBT Treatment Research:Randomized Clinical Trials 20 RCTs 9 RCTs have been completed by the Cohen,Mannarino, and Deblinger team Two RCTs in the Democratic Republic of Congo forsex trafficked girls and boy soldiers Study in Zambia by Laura Murray One RCT in Norway by Tine Jensen and her group The Netherlands: TF-CBT vs. EMDR One RCT just finished in Germany

Treatment Research Studies have been conducted with children exposed tosexual abuse, domestic violence, traumatic losses, civilwar, sex trafficking and multiple traumas Improved PTSD, depression, anxiety, shame and behaviorproblems compared to client-centered or nondirectivetherapy Improved parental distress, parental PTSD, parentalsupport, and parental depression compared to clientcentered or nondirective treatment

TF-CBT Components PRACTICE Psychoeducation and Parenting Skills Relaxation Affective Modulation Cognitive Processing Trauma Narrative In Vivo Desensitization Conjoint parent-child sessions Enhancing safety and social skills

Components- and Phase-Based TreatmentPRACTICE COMPONENTS:Psychoeducation; Parenting SkillsRelaxation SkillsAffective regulation SkillsCognitive processing SkillsTrauma narration and processingIn vivo mastery of trauma remindersConjoint child-parent sessionsEnhancing safetyTF-CBT PHASES:STABILIZATION PHASETN PHASEINTEGRATION PHASE

TF-CBT Dissemination

The National Child TraumaticStress Network The National Child Traumatic Stress Network was launched byCongress in 2000 as part of the Children’s Health Act The NCTSN is supported through funding from the Donald J.Cohen National Child Traumatic Stress Initiative, administered bythe Department of Health and Human Services (DHHS), Center forMental Health Services (CMHS), Substance Abuse and MentalHealth Services Administration (SAMHSA).

National Child Traumatic Stress NetworkMission StatementThe mission of the National Child Traumatic StressNetwork (NCTSN) is to raise the standard of care andimprove access to services for traumatized children, theirfamilies, and communities throughout the United States.

National Child Traumatic Stress Network(NCTSN)Our Center for Traumatic Stress in Children andAdolescents has been a Treatment Services andDevelopment Center in the NCTSN since its inceptionin 2001

NCTSN Learning Collaboratives NCTSN has sponsored three national TF-CBT LearningCollaboratives and several regional TF-CBT LearningCollaboratives Other states (Delaware; Washington; Connecticut;South Carolina; North Carolina; Texas; Michigan;Massachusetts), based on the NCTSN model, havesponsored their own state-wide TF-CBT LearningCollaboratives

Child and Adolescent Trauma Treatment Services(CATS) Project CATS Project: TF-CBT used following 9-11terrorist attacks in NYC demonstratedsignificantly greater improvement in PTSDamong 500 children receiving TF-CBT thanthose receiving usual treatment.

National and InternationalDissemination Projects 26 states have sponsored/are sponsoring TF-CBTdissemination projects, including Nevada, Utah,Washington, Connecticut, Delaware, Arkansas, New York,Illinois, South Carolina, California, New Jersey,Pennsylvania, and North Carolina. International dissemination projects in Norway, Germany,the Netherlands, Japan, Sweden, Cambodia and Zambia

Translations Our book has been translated into Dutch,German, Korean, Japanese, Chinese,Russian,and Polish. Other translations currently underway.

TF-CBT Web-based Dissemination TF-CBTWeb (www.musc.edu/tfcbt)- 312,806 learners have registered for course- 171,154 have completed the full course- In last six months, the rate of new learners is123/day CTGWeb (www.musc.edu/ctg) TF-CBTConsult (www.musc.edu/tfcbtconsult)

TF-CBTWebwww.musc.edu/tfcbtTF-CBTWeb is aweb-based,distance educationtraining course forlearning TraumaFocused CognitiveBehavioral Therapy(TF-CBT).

TF-CBTWebwww.musc.edu/tfcbt Web-based learning Learn at your own pace Learn when you want Learn where you want Return anytime 10 hours of CETF-CBTWeb is offeredfree of charge.

New Cognitive Processing Video GameTF-CBT TRIANGLE OF LIFE Currently available on the Google Play Store Currently available on the Apple Store

TF-CBT Train-the-Trainer Program 70 trainers have been trained in four differentcohorts over the past 12 years Trainers stay connected to TF-CBT developersthrough regular meetings, sharing of trainingresources and research, and TF-CBT Google group. Our trainers have conducted approximately 1500 inperson U.S. trainings over the past 12 years. About75,000 clinicians have been trained.

TF-CBT Training Package TF-CBTWeb Two-day live TF-CBT training At least 12 follow-up consultation callsOR TF-CBTWeb TF-CBT Learning Collaborative

International Train-the-Trainer Program The first cohort was completed in April, 2013. Four countries and a total of 11 participants:- Norway- Sweden- the Netherlands- Germany Current Asian TTT Program with MH professionals fromJapan and Singapore- started in July, 2016

International TTT Program (cont’d)New cohort for our European TTT program starting April, 2017 Norway Sweden Germany the Netherlands Finland

TF-CBT Train-the-Supervisor Program Three cohorts of 55 supervisors from around the country Major goal of the TTS Program is local sustainability of TFCBT within a specific organization. Program consists of 15 months of conference calls;distribution of supervisory materials and other resources Graduates of TTS Program can provide TF-CBT supervisionthat counts toward therapist certification

TTS Program (cont’d) Will start new TTS cohort this spring with TF-CBT supervisorsfrom across the U.S. Will initiate TTS program later this spring with TF-CBTsupervisors from Los Angeles County in conjunction withL.A. Department of Mental Health

TF-CBT Therapist Certification Program Therapist Certification Program started in September,2013. Website: https://tfcbt.org There are currently about 1800 certified TF-CBTtherapists in the U.S. and Canada

The Future of TF-CBT

Current Formal TF-CBT Applications TF-CBT Implementation Manual for Military Families TF-CBT Implementation Manual for Youth in ResidentialFacilities TF-CBT Implementation Manual for Children in Foster Care

Ongoing/Planned TF-CBT ApplicationsClient Populations LGBTQ youth Commercially sexually exploited children (CSEC) Youth with developmental disabilities, including those onthe autism spectrum

New TF-CBT Technology TF-CBTWeb 2.0 will be available later this year- Improved videos- Applications to complex trauma Working with Ken Ruggiero of Medical University of SouthCarolina to develop apps for the PRACTICE components PTSD Screening app: Screen Team- For younger children ages 7-12- Based on Foa’s Child PTSD Symptom Scale

TF-CBT Therapist Certification Program Therapist certification expires after five years Current work is focused on recertification criteria andcontinuing education- Continuing education will be available at no cost athttps://tfcbt.org- Recertification will be for five years- Certified therapists will be emailed one year prior toexpiration of their certification to inform them about CErequirements and renewal

TF-CBT Research International RCTs, including in Kenya and Tanzania TF-CBT outcome research in Japan for children affected bythe 2011 tsunami/earthquake Research focused on TF-CBT processes- Delaware study demonstrating how parental treatmentvariables affect child outcomes- Study by Sharma-Patel & Brown- youth with higheremotional dysregulation improve the most after traumanarration and processing

Maya Angelou:“The world is changed one child at atime”Thank you for all you do fortraumatized children!

2/3 of youth age 16 and older have experienced traumatic life events 25% of all girls and 10-15% of all boys have been sexually assaulted by their 18th birthday 20-25% of all youth have witnessed intimate partner violence School and electr